Where Even Nightmares Are Classified: Psychiatric Care at Guantánamo

She tried to block out thoughts of her 4-year-old daughter. Dr. Rosecrans, a Navy psychiatrist, had been warned not to speak about her family or display anything personal, clues that might allow a terrorism suspect to identify her.

Patients called her “torture bitch,” spat at her co-workers and shouted death threats, she said. One hurled a cup of urine, feces and other fluids at a psychologist working with her. Even interviewing prisoners to assess their mental health set off recriminations and claims that she was torturing them. “What would your Jesus think?” they demanded.

Dr. Rosecrans, now retired from the Navy, led one of the mental health teams assigned to care for detainees at the island prison over the past 15 years. Some prisoners had arrived disturbed — traumatized adolescents hauled in from the battlefield, unstable adults who disrupted the cellblocks. Others, facing indefinite confinement, struggled with despair.

Then there were prisoners who had developed symptoms including hallucinations, nightmares, anxiety or depression after undergoing brutal interrogations at the hands of Americans who were advised by other health personnel.

At Guantánamo, a willful blindness to the consequences emerged. Those equipped to diagnose, document and treat the effects — psychiatrists, psychologists and mental health teams — were often unaware of what had happened.

Sometimes by instruction and sometimes by choice, they typically did not ask what the prisoners had experienced in interrogations, current and former military doctors said. That compromised care, according to outside physicians working with legal defense teams, previously undisclosed medical records and court filings.

Dozens of men who underwent agonizing treatment in secret C.I.A. prisons or at Guantánamo were left with psychological problems that persisted for years, despite government lawyers’ assurances that the practices did not constitute torture and would cause no lasting harm, The New York Times has reported. Some men should never have been held, government investigators concluded. President-elect Donald J. Trump declared during his campaign that he would bring back banned interrogation tactics, including waterboarding, and authorize others that were “much worse.”

In recent interviews, more than two dozen military medical personnel who served or consulted at Guantánamo provided the most detailed account to date of mental health care there. Almost from the start, the shadow of interrogation and mutual suspicion tainted the mission of those treating prisoners. That limited their effectiveness for years to come.

Psychiatrists, psychologists, nurses and technicians received little training for the assignment and, they said, felt unprepared to tend to men they were told were “the worst of the worst.” Doctors felt pushed to cross ethical boundaries, and were warned that their actions, at an institution roiled by detainees’ organized resistance, could have political and national security implications.

Rotations lasted only three to nine months, making it difficult to establish rapport. In a field that requires intimacy, the psychiatrists and their teams long used pseudonyms like Major Psych, Dr. Crocodile, Superman and Big Momma, and referred to patients by serial numbers, not names. They frequently had to speak through fences or slits in cell doors, using interpreters who also worked with interrogators.

Wary patients often declined to talk to the mental health teams. (“Detainee refused to interact,” medical records note repeatedly.) At a place so shrouded in secrecy that for years any information learned from a detainee was to be treated as classified, what went on in interrogations “was completely restricted territory,” said Karen Thurman, a Navy commander, now retired, who served as a psychiatric nurse practitioner at Guantánamo. “‘How did it go?’” Or “‘Did they hit you?’ We were not allowed to ask that,” she said.

Dr. Rosecrans said she held back on such questions when she was there in 2004, not suspecting abuse and feeling constrained by the prison environment. “From a surgical perspective, you never open up a wound you cannot close,” she said. “Unless you have months, years, to help this person and help them get out of this hole, why would you ever do this?”

The United States military defends the quality of mental health care at Guantánamo as humane and appropriate. Detainees, human rights groups and doctors consulting for defense teams offer more critical assessments, describing it as negligent or ineffective in many cases.

Those who served at the prison, most of whom had never spoken publicly before, said they had helped their patients and had done the best they could. Given the circumstances, many focused on the most basic of duties.

“My goal was to keep everyone alive,” Dr. Rosecrans said.

“We tried to keep the water as smooth as possible,” Ms. Thurman said.

“My job was to keep them going,” said Andy Davidson, a Navy captain, now retired, and psychologist.

 Dr. Shay Rosecrans, who led a mental health team at Guantánamo in 2004, said some patients had viewed her as “a representative of the government.” CreditMichael Spooneybarger for The New York Times

Conflicted Care

When Dr. Rosecrans worked briefly at the Navy’s hospital at Guantánamo as a young psychiatrist in 1999, it was a sleepy assignment. She saw only a few outpatients each week, and there was no psychiatric ward on the base, which was being downsized.

But after Al Qaeda’s 2001 terror attacks on New York and the Pentagon, and the subsequent American-led invasion of Afghanistan, detainees began pouring into the island in early 2002 — airplane loads of 20 to 30 men in shackles and blacked-out goggles. “We were seeing prisoners arriving with mental problems,” said Capt. Albert Shimkus, then the hospital’s commanding officer.

There were no clear protocols for treating patients considered to be “enemy combatants,” rather than prisoners of war, said Captain Shimkus, who is now retired. But he set out, with the tacit support of his commanders, to provide a level of care equivalent to that for American service members. He transformed a cellblock into a spartan inpatient unit for up to 20 patients and brought in Navy psychiatrists, psychiatric nurses and technicians to be available around the clock.

Many of them had little or no predeployment training, experience working in a detention facility or familiarity with the captives’ languages, cultures or religious beliefs. They soon heard talk of the threat the prisoners posed.

“The crew that was there before us scared the heck out of us,” said Dr. Christopher Kowalsky, who as a Navy captain led the mental health unit in 2004. He and Dr. Rosecrans said colleagues had admonished them for getting too close to patients. “‘Don’t forget they’re criminals,’” she was told.

Those arriving in later years attended a training program at a military base in Washington State. “You heard all these things about how terrible they are: Not only will they gouge your eyes out, but they’ll somehow tell their cohorts to go after your family,” said Daniel Lakemacher, who served as a Navy psychiatric technician. “I became extremely hateful and spiteful.”

Peering through small openings in cell doors, he and other technicians handed out medications, watched prisoners swallow them and ran through a checklist of safety questions — “Are you having thoughts of hurting yourself?” “Are you seeing things that aren’t there?” — through interpreters or English-speaking detainees in nearby cells. (“Talk about confidentiality!” Dr. Davidson said. “It’s just a whole other set of rules.”)

Conflicts arose between health professionals aiding interrogators and those trying to provide care. Army psychologists working with military intelligence teams showed up in 2002 and asked to be credentialed to treat detainees. “I said no, because they were there for interrogations,” Captain Shimkus said.

In June of that year, Maj. Paul Burney, an Army psychiatrist, and Maj. John Leso, an Army psychologist, both of whom had deployed to Guantánamo to tend to the troops, instead were assigned to devise interrogation techniques. In a memo, they listed escalating pressure tactics, including extended isolation, 20-hour interrogations, painful stress positions, yelling, hooding, and manipulation of diet, environment and sleep.

But they also expressed caution. “Physical and/or emotional harm from the above techniques may emerge months or even years after their use,” the two men warned in their memo, later excerpted in a Senate Armed Services Committee report. They added that the most effective interrogation strategy was developing a bond.

A version of the memo, stripped of its warnings, reached Defense Secretary Donald H. Rumsfeld. In December 2002, he approved many of the methods for Guantánamo, some of them similar to the “enhanced interrogation techniques” used by the C.I.A. at secret prisons overseas. After objections from military lawyers, he made some modifications but gave commanders license to use 24 techniques. Some of them later migrated to military prisons in Afghanistan and Iraq, including Abu Ghraib, where they morphed into horrific abuses.

“I think it was the absolute wrong way to proceed,” Dr. Burney, who has not previously commented publicly, said of the approved techniques. “I so wish I could go back and do things differently.”

He and Dr. Leso created the Behavioral Science Consultation Team, or BSCT (pronounced “biscuit”), to advise and sometimes rein in military interrogators, many of them young enlisted soldiers with little experience even interviewing people. The interrogators subjected some detainees at Guantánamo to loud music, strobe lights, cold temperatures, isolation, painful shackling, threats against family members and prolonged sleep deprivation, according to the Justice Department’s inspector general.

The government has never quantified how many prisoners underwent that treatment. In four cases, military leaders approved even harsher interrogation plans. At least two were carried out.

Dr. Burney said he and Dr. Leso took turns observing the questioning in 2002 of Mohammed al-Qahtani, who was accused of being an intended hijacker in the Sept. 11 attacks and, it later emerged, had a history of psychosis. Among other things, he was menaced with military dogs, draped in women’s underwear, injected with intravenous fluids to make him urinate on himself, put on a leash and forced to bark like a dog, and interrogated for 18 to 20 hours at least 48 times, government investigators found.

Mr. Qahtani was led to believe that he might die if he did not cooperate, Dr. Burney said in a statement provided to the Senate committee. When Mr. Qahtani asked for a doctor to relieve psychological symptoms, the interrogators instead performed an exorcism for “jinns” — supernatural creatures that he believed caused his problems.

In 2009, a Department of Defense official overseeing military commissions refused to prosecute Mr. Qahtani, telling The Washington Post that his mistreatment had amounted to torture. In 2012, a federal judge found Mr. Qahtani incompetent to help challenge his detention.

Those providing mental health care at Guantánamo quickly aroused the suspicions of some prisoners, who called them devils, criminals and dogs.

“Nobody trusted them,” said Lutfi bin Ali, a Tunisian who was sent to Guantánamo after being subjected to harsh conditions at what he described as an American jail overseas. “There was skepticism that they were psychiatrists and that they were trying to help us,” he said by phone from Kazakhstan, where he was transferred to in 2014. He still suffers intermittently from depression.

Dr. Davidson, who treated prisoners at Guantánamo during part of 2003, recalled the hostility. “I can tell the guy until the cows come home, ‘Hey, I’m just here for mental health,’” he said. “‘No, you’re not,’” he imagined the patient thinking, “‘you’re the enemy.’”

 Dr. Christopher Kowalsky, who was in charge of the mental health unit in 2004, said detainees had begged him not to record their diagnoses. “They’re going to use that” in interrogations, they told him.CreditLexey Swall for The New York Times

One day on the cellblocks, Dr. Rosecrans heard detainees warn others that she could not be trusted. “Some of my patients hated me,” she said. “They saw me as a representative of the government.”

She and other clinicians who felt uncomfortable walking around the prison grounds relied mostly on guards to identify detainees who needed help and to take them to an examination room, where they would be chained to the floor.

Interpreters were in such short supply at times that they worked with both the mental health teams and the interrogators. “See where that could be a problem?” Dr. Rosecrans asked.

All of that fed the conviction among detainees that information about their mental health was being exploited by interrogators. “If you complain about your weak point to a doctor, they told that to the interrogators,” said Younous Chekkouri, a Moroccan, now released.

He recalled seeing one psychologist working alongside interrogators and then treating detainees at the prison. Only years later, he said, did he feel he could trust certain psychiatrists there. He said he still suffered from flashbacks and anxiety after being beaten at a military prison in Afghanistan, and kept in isolation and shown execution photos at Guantánamo.

Captain Shimkus, who oversaw patient care, said some clinicians had expressed concerns about the blurred lines between medical care and interrogation. He said he had allowed one psychiatrist, who was disturbed by the lack of confidentiality, to temporarily recuse himself from caring for patients because the doctor believed “the patient-physician relationship was compromised.”

The United States Southern Command told health care providers at Guantánamo in 2002 that their communications with patients were “not confidential.” At first, interrogators had direct access to medical information. Then, the BSCT psychologists acted as liaisons.

They regularly read patient records in the psychiatry ward, said Dr. Frances Stewart, a retired Navy captain and psychiatrist who treated detainees in 2003 and 2004. As a consequence, she said, “I tried to document just the things that really needed to be documented — things like ‘the patient has a headache; we treated it with Tylenol’ — not anything terribly sensitive. It was not a perfect solution, but it was probably the best solution I could come up with at the time.”

Dr. Kowalsky, a psychiatrist, said patients had begged him not to record their diagnoses. “They’re going to use that,” some detainees told him.

The International Committee of the Red Cross, during a June 2004 visit, documented the same complaint. Medical files, the group said in confidential remarks revealed in The Times, were regularly used to devise strategies for interrogations that it called “tantamount to torture.” Interrogators’ access to medical records was a “flagrant violation of medical ethics.” The Pentagon disputed that the records were used to harm detainees.

Dr. Kowalsky said he clashed with a BSCT psychologist, Diane Zierhoffer, who showed up in the psychiatric unit to look at patient records in 2004. (Dr. Zierhoffer, in an email, said her intent in accessing records had been to “ensure health care was not interfered with.”)

“We’re here to help people,” Dr. Kowalsky recalled once telling her.

“We’re here to protect our country,” he said she had responded, later asking: “Whose side are you on?”A prison cell, staged for journalists, in the now-closed Camp 5 at Guantánamo.CreditBryan Denton for The New York Times

They Didn’t Ask

Sometimes it wasn’t clear what was forbidden or what had just become practice, but it had the same effect: Psychiatrists and psychologists said they had almost never asked a detainee about his treatment by interrogators, either at Guantánamo or at the C.I.A. prisons.

Mohamedou Ould Slahi, who was released to his native Mauritania in October after 14 years at Guantánamo, told a doctor on his legal team that military mental health providers did not ask him about possible mistreatment, according to a sealed court report obtained by The Times. Mr. Slahi did not volunteer the information because he was afraid of retaliation, he wrote in his prison memoir, “Guantánamo Diary.”

Mr. Slahi endured some of the most brutal treatment there. Investigations by the Army, the Justice Department and the Senate largely corroborated his account of being deprived of sleep; beaten; shackled in painful positions; forced to drink large amounts of water; isolated in darkness and exposed to extreme temperatures; stripped and soaked in cold water; told that his mother might be sent to Guantánamo; and sexually assaulted by female interrogators.

Decades earlier, he had joined the insurgency against the Soviet-backed government in Afghanistan, a cause supported by the United States. In 1991, he attended a Qaeda training camp, and was later suspected of recruiting for the terrorist group. A federal judge ordered him freed in 2010 for lack of evidence, but an appeals court overturned the decision. In July, a military review board recommended his transfer.

Prison medical records show that Mr. Slahi, a computer specialist with no history of mental illness, received anti-anxiety medicine, antidepressants, sleeping pills and psychotherapy, and that he had recurring nightmares of being tortured in the years after his ordeal.

Dr. Vincent Iacopino, a civilian physician who evaluated Mr. Slahi in 2007 for his defense team, criticized psychologists and psychiatrists at Guantánamo for failing “to adequately pursue the obvious possibility of PTSD,” or post-traumatic stress disorder, linked to severe physical and mental harm, the records show. Dr. Iacopino said military doctors had medicated Mr. Slahi for his symptoms instead of trying to treat his underlying disorder, which had “profound long-term and debilitating psychological effects.” Last year, one of Mr. Slahi’s lawyers described him as “damaged.”

He was one of nearly 800 men incarcerated at Guantánamo over the years and one of several whose confessions were tainted by mistreatment and disallowed as evidence by the United States. Many prisoners were Qaeda and Taliban foot soldiers later deemed to pose little threat. Some were victims of mistaken identity or held on flimsy evidence.

Dr. Burney, who assisted the interrogators, said he had seen many detainees’ files. “It seemed like there wasn’t a whole lot of evidence about anything for a whole lot of those folks,” he said.

Books, movies and video games available to “highly compliant” and “compliant” detainees at Guantanámo in September. CreditBryan Denton for The New York Times

After the C.I.A.’s secret prisons were shut in 2006, Guantánamo took in more than a dozen so-called high-value detainees, including those accused of plotting the Sept. 11 attacks. Some doctors at Guantánamo said they had been instructed, in briefings or by colleagues, not to ask these former “black site” prisoners about what had happened there. Virtually everything about these captives was classified until a Senate Intelligence Committee report in 2014 disclosed grisly details about torture.

“You just weren’t allowed to talk about those things, even with them,” said Dr. Michael Fahey Traver, an Army psychiatrist at Guantánamo in 2013 and 2014. He was assigned to treat only high-value detainees kept in Camp 7, Guantánamo’s most restricted area, so that he did not inadvertently pass sensitive information to other prisoners.

If a detainee raised the subject of his prior treatment, Dr. Traver was to redirect the conversation, he said his predecessor had told him. Among his patients were Ramzi bin al-Shibh, accused of helping plot the Sept. 11 attacks, and Abd al-Rahim al-Nashiri, who was charged in the 2000 bombing of the American destroyer Cole and endured some of the C.I.A.’s most extreme interrogation techniques, including waterboarding.

At the request of prosecutors, a military psychiatrist and two military psychologists went to Guantánamo in 2013 to assess Mr. Nashiri’s competency to assist in his defense. The panel concluded that, while competent, he suffered from PTSD and major depression.

The military commission trying Mr. Nashiri held a hearing in 2014 on the adequacy of his mental health care. Shortly before the hearing, Dr. Traver removed a previous diagnosis by another Guantánamo psychiatrist that Mr. Nashiri had PTSD. “I didn’t think he met that diagnosis,” Dr. Traver said in an interview.

Dr. Sondra Crosby, an expert on torture who consulted for Mr. Nashiri’s defense, disagreed. Dr. Crosby, an internist, said his treatment was inadequate. “He suffers chronic nightmares,” she testified in an affidavit, which “directly relate to the specific physical, emotional and sexual torture inflicted upon Mr. al-Nashiri while in U.S. custody.” The content of his nightmares, she wrote, was classified.

The commission judge, citing a Supreme Court ruling that prisons must provide health care, found insufficient evidence of “deliberate indifference” to his medical needs.

What went on after prisoners were summoned for interrogations at Guantánamo was mostly a mystery to the mental health personnel, some of them said. Even when patients returned from sessions “looking terrible,” said Mr. Lakemacher, the former psychiatric technician, “that was not to be addressed.” (After his deployment, Mr. Lakemacher said, he regretted taking part in what he came to consider the unjust, indefinite detention of prisoners. He later was discharged from the Navy as a conscientious objector.)

Daniel Lakemacher, a psychiatric technician at Guantánamo in 2007 and 2008. Even when detainees returned from interrogations “looking terrible,” he said, “that was not to be addressed.” CreditJoshua Lott for The New York Times

Some doctors, on their own, shied away from the subject of interrogation tactics. “I didn’t want to get near that stuff,” Dr. Rosecrans said. “Men would say, ‘When I got here, they treated me like a dog,’” or that they were humiliated, she said, but she refrained from inquiring, in part, “to preserve their dignity.”

When detainees claimed to have been tortured or maltreated, “you didn’t know if it was true or not,” she said.

“Is it PTSD, or is it delusional disorder?” she said, adding, “I was in such a vacuum.”

But Dr. Rosecrans had little reason to suspect abusive treatment, she said, because some prisoners seemed eager to go to interrogation sessions, which they called “reservations.” Interrogators, working in trailers separate from the structures where detainees were housed, doled out rewards like snack food or magazines; speaking with them broke the boredom for detainees.

“It was a way to get out of their cell,” said Ms. Thurman, the nurse practitioner. “They’d do anything, I think, to do something different for the day.”

Dr. Stewart, the Navy captain who treated detainees in 2003 and 2004, said she had never noticed any men in distress after returning from interrogations. But she typically did not ask what had happened there or try to focus on trauma in therapy, she said. “I didn’t want to stir up anything that might make things worse,” she said.

PTSD, generally thought to be the most common psychiatric illness resulting from torture, was rarely diagnosed at Guantánamo. Dr. Rosecrans and other doctors who served there said the diagnosis did not matter because they could still treat the symptoms, like depression, anxiety or insomnia.

Standard treatment for the disorder involves building trust and revisiting traumatic experiences, which can temporarily exacerbate symptoms. That was impractical at Guantánamo, Dr. Rosecrans and others contended, where detainees were under stress and often unwilling to talk about what had happened to them.

“These folks were in acute survival mode,” Dr. Rosecrans said. Most of their concerns were “here-and-now or future-oriented, not backward-looking.”

Dr. Davidson said he had not considered doing full histories to diagnose PTSD. But later, he said, after he mulled over the experiences of American soldiers, “the thought was occurring to me: How come our guys get PTSD and they don’t? Well, probably because I’m not asking the right questions.”

Dr. Jonathan Woodson, a former assistant secretary of defense for health affairs, who was the Pentagon’s top health official from 2010 until this spring, said he was unaware that mental health providers at Guantánamo had avoided asking detainees about coercive interrogations. He said his policy was that physicians should not be constrained in what they could ask patients.

“You would take the history of someone who is exhibiting symptoms,” he said. “In PTSD, it’s almost automatic.”

Brig. Gen. Stephen N. Xenakis, a retired Army psychiatrist who consulted for the legal defense teams of many detainees, said, “You cannot provide psychological treatment if you never look into what happened to them when they are tortured.” He added: “The psychologists and psychiatrists at Guantánamo are not meeting the standards of care of the military or the profession.”

Military officials disagree. Capt. John Filostrat, a spokesman for Joint Task Force Guantanamo, said, “We are doing a tough job, and we are doing it well.”Dr. Elspeth Cameron Ritchie was dispatched to Guantánamo in 2002 after a series of suicide attempts by detainees. CreditLexey Swall for The New York Times

‘No One Is Dying’

Mental health providers recall troubled men they helped — an Afghan farmer who attempted suicide, a psychotic Yemeni man stabilized and removed from isolation, a traumatized Saudi patient who began opening up. Some doctors describe Guantánamo as their most difficult deployment. They were cast in unfamiliar roles: recipients of pleas for privileges, inadvertent disciplinarians ordering “self-harm” restrictions like the removal of prayer beads or sheets, enablers of policies that made them deeply uncomfortable.

“Every day was an ethical challenge, quite frankly,” Dr. Davidson said.

Procedures at Guantánamo changed over time. Limits on abusive tactics were tightened by Congress in 2005, then banned by President Obama in 2009.

But even after interrogation conditions eased, and after BSCT personnel were denied access to medical records in 2005, many detainees remained distrustful. That made it “a real challenge for the physicians treating them to even determine what was a real problem and what wasn’t,” said Dr. Bruce Meneley, a Navy captain, now retired, who commanded the medical group at Guantánamo from 2007 to 2009.

Some men, worried about being seen as weak or crazy, would disclose only physical complaints like stomach aches, headaches and insomnia. Dr. Traver said sleeping pills had been the sole medication that the high-value detainees he treated would agree to take.

The doctors were unfamiliar with the ways psychiatric illness could be expressed in some cultures. A number of prisoners, Dr. Rosecrans recalled, described being plagued by jinns. She and others prescribed powerful anti-psychotics, but she remembers wondering, “Are we doing the right thing?”

After years of incarceration at a place that became a symbol of American injustice — a legal black hole where men often did not know what they were accused of and had few avenues of legal recourse — many detainees, seeing themselves as political prisoners, seethed with resentment or were overcome by depression.

Over and over, the psychiatrists recalled, men would ask, “Why am I here?” or “What’s my future?” — questions the doctors could not answer. Sometimes, they said, their work felt futile.

“The environmental factors outweighed so much of what we did,” Dr. Davidson said. “We had so many people who were depressed. Well, I would be really depressed, too, if they stuck me in a place, I had no idea where I was, and I had no idea if or when I was going to leave. That is the definition of depression, I think — not having any control over my situation.”

It was often difficult to discern, doctors said, who was genuinely troubled, who was seeking attention and, most worrisome, who was in danger. “All of the leaders that I met were like, ‘No one is dying on my watch,’” Dr. Rosecrans said.

In 2004, after men began refusing food to protest their detention, she was asked to devise a protocol for evaluating the mental health of those on prolonged hunger strikes. Dr. Rosecrans believed that mentally competent people had the right to choose not to eat — even if that meant they would die. The American Medical Association and international medical organizations endorse that position. But the government has insisted on forced feedings, which are permissible in federal prisons. Detainees have described the procedures used at Guantánamo as particularly painful, with some likening them to torture.

Musa’ab al-Madhwani, a Yemeni captured in Pakistan and suspected in a terrorism plot, the evidence for which the United States eventually largely disavowed, joined a large group of hunger strikers in 2013 protesting conditions at the prison. He had arrived at Guantánamo in 2002, barely out of his teens, after being held at a C.I.A. prison. He had violent nightmares and other psychiatric problems after harsh treatment there, his medical records show.

Over the years, judges threw out his admissions during interrogations, finding they were tainted by mistreatment at the C.I.A. prison and coercive questioning at Guantánamo. But his detention stretched on, and after both of his parents died, Mr. Madhwani said in a letter to a federal judge that he was “utterly hopeless.” He added: “I have no reason to believe that I will ever leave this prison alive. It feels like death would be a better fate than living in these conditions.”

It was up to the psychiatrists and psychologists to decide how seriously to take such statements, and how to respond to them. “What do you do if they say they’re suicidal?” said Dr. Elspeth Cameron Ritchie, an Army colonel, now retired, and psychiatrist who was dispatched to Guantánamo in late 2002 after a spate of attempts. “Are they really suicidal, or are they manipulating the system?”

More than 600 “suicide gestures” had been recorded at Guantánamo by 2009, with more than 40 categorized as suicide attempts, according to a medical article. The doctors had to distinguish genuine attempts — reflecting desperation or, as American officials contended, a desire for martyrdom — from acts aimed at improving their conditions of confinement.

To date, at least six deaths have been have classified as suicides, though critics have raised questions about foul play in some cases. One Guantánamo commander referred to three of them, which were simultaneous, as acts of warfare against America. Several of the dead had been treated by mental health providers for serious disorders.

Only 60 prisoners remain at Guantánamo, and about a third of them have been approved for transfer. Ten have been charged with or convicted of crimes by the military commissions system.

Capt. Richard Quattrone of the Navy, who served until September as the prison’s chief medical officer, said just a small number of detainees had chronic mental health issues. “The things we see are about day-to-day issues, anxiety over their release, and when it will happen, or if it will happen,” he said.

“Whatever happened in the past,” he added, “I think we’ve now built trust with the medical personnel.”

Looking back, Dr. Rosecrans said she and her colleagues had faced many obstacles. For certain prisoners, the very tool that psychiatrists and psychologists most rely on — asking questions — would forever evoke interrogations. And the secrecy complicated everything.

“Did we know what was going on? Or what might have been going on?” Dr. Rosecrans asked. “I didn’t know any of that intel stuff.”

But, she added, “we did the job of treating patients.”

Guantánamo stayed with her in unexpected ways. Relaxing on a cruise soon after leaving the prison assignment, she tried to pose her daughter for a photo. When the child refused to put down a stuffed animal, Dr. Rosecrans threatened to throw it overboard.

“You’re a little terrorist!” she erupted.